| NPI | 1063864346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: CT 62653) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2019-06-21 |